Infant Name Parent Name

Infant D.O.B. Telephone

Sleep pattern Good Average Poor Address

Eating / feeding Good Average Poor Email

Digestive problems Constipation Wind Bloating Colic

Immune system Prone to infections Colds Sinuses Sore throats

Medication Please detail any regular medication required

Skin type Dry Sensitive Other

Contraindications that RESTRICT treatment. Please tick if Please contact me before each session if you
any of these conditions apply to your baby have any health questions or concerns regarding
whether your baby should have massage.
o Fever Always contact your GP, midwife or heath
o Contagious or infectious disease visitor if you have any concerns about your
babys health and wellbeing
o Recent fractures, sprains and swelling
o Recent haemorrhage Contraindications needing GP / medical
o Jaundice permission:
o Meningitis Recent operation / surgery
o Childhood leukaemia Congenital heart condition
o Osteoporosis Congenital dislocation of the hip
o Recent cut/abrasion/ brittle bones Spastic conditions,
o Diarrhoea and vomiting Dysfunction of the nervous syst9m
o Recent immunisation (minimum 48 hours) Epilepsy
Asthma
o Skin disorders / inflammatory skin conditions
o Skin allergies o Cuts and bruises In circumstances where medical permission
O Unhealed navel cannot be obtained the parent / guardian must
o Cradle cap indemnify the condition in writing prior to the
treatment

Declaration (Please read this section carefully and sign below)

"l the undersigned have completed the form as fully and accurately as I can. I believe the details to be correct
and consent to having treatment/ session with the practitioner detailed on this form. I release the practitioner
from any negligent misrepresentation that may be contained in this form"

For therapist use only - TREA TMENT NOTES

PRINT NAME:

SIGNATURE:

DATE:

Sally Davis Massage for Wellbeing 07974 746452 www.massageforwellbeing.co.uk